individual plan

enrollment application
Lovelace iPlan Enrollment Application
ENROLLMENT APPLICATION
• This Application is a legal document and becomes part of the Contract. Be sure to answer each question completely
and thoroughly.
• Only the parent/legal guardian may apply for coverage for a dependent child under age 18. The parent/legal guardian
must complete this form for the child. If applying for child coverage only, provide child’s information in the “Primary
Applicant” section of this Application. Provide parent/legal guardian’s information in the “Individual Plan for
Children Only” section.
• All legal-age Applicants or the parent/legal guardian of a minor child Applicant must personally sign and date this
Application. Questions must be answered with complete details given for any “yes” answers, where indicated. If your
spouse or any dependent(s) age 18 or over are also applying for coverage, they must personally sign and date this
Application on the appropriate signature line.
• This Application must be completed with black or blue ink only. Please print legibly. Illegible Applications or Applications
completed in pencil or erasable ink will be returned. Changes or corrections to this Application must be made by striking
out the change/mistake with a single line so that the initial markings can still be read, then writing the correction nearby
and initialing the change. Applications containing correction tape or fluid will be returned.
• Original Applications with original signatures are required in order to issue a policy. Faxed Applications are acceptable to
initiate underwriting review.

ELIGIBILITY REQUIREMENTS
New Mexico Residency –
• All Applicants must be under age 65 and New Mexico residents as defined by State law. If residency is questionable,
proof of residency may be required (i.e., NM Driver’s license or income tax documents).
Citizenship –
• Foreign nationals legally residing in New Mexico, who meet the New Mexico Residency requirements specified above, may
apply for coverage.
Employer Sponsored Coverage –
• The Lovelace iPlan provides a coverage option for individuals and is not employer-sponsored group coverage or meant to
be a replacement for employer-sponsored group coverage. Premiums for the Lovelace iPlan are the full responsibility of the
applicant/insured. An employer may not contribute any portion of the premium for Lovelace iPlan coverage.
Coverage for Primary Applicant and/or Dependents –
• Legal dependent(s) who are also students out-of-state, may apply for and retain coverage as long as New Mexico remains
their state of residency.

SUBMISSION OF THE APPLICATION

• If using an insurance broker, please return this Application to your broker.

• If not using an insurance broker, please mail this Application to: Lovelace Insurance Company
Individual Plan Sales
4101 Indian School Road NE
Albuquerque, NM 87110

• For assistance, please call your broker or call Lovelace Insurance Company Individual Sales at 505.232.1982
or 877.232.1982

BROKER INFORMATION – to be completed by Broker who is licensed and appointed with LINC. Broker also
must completed Lovelace iPlan certification.

Broker Name: Agency Name: Pay Broker

Sherrie Williams Willaims Sales & Services, LLC X Pay Agency
Broker Signature: Date:
X

LINC 180-0507 Page 1 of 6

Lovelace iPlan Enrollment Application
SECTION I. PERSONS APPLYING FOR COVERAGE – All Applicants listed on this Application must reside
at the same residential address listed below. Any Applicant with a different residential address must complete
a separate Application. If applying for child coverage only, please list the child(ren)’s information in this section
and your information in the “Individual Plan for Children Only” section.
Are you age 65 or older? Yes No
• Applicants who are age 65 or older are not eligible to enroll in the Lovelace Individual Plan. However, you may be eligible
to enroll in the Lovelace Senior Plan. Please call 505.262.3757or 800.262.3757 to obtain enrollment information.
PRIMARY APPLICANT
Last Name, First Name, MI: Date of Birth Social Security # Gender Height Weight (lbs.)
(mo/day/yr): M (ft., in.)
F
Residential Address: Apt.# City: County: State: Zip Code:

Home Telephone: Business Telephone Cellular Telephone: E-Mail Address (if available):

Mailing Address: Apt.# City: County: State: Zip Code:

(if different from Residential Address

Choose plan option: 20% Co-Insurance Plans: $250 $500 $750 $1000 $2000
30% Co-Insurance Plans: $1500 $2000 $4000
Please indicate if this Application is a: Requested Effective Date (Please note, actual effective date may be different):
New Application Re-Application
Where did you hear about the Lovelace Individual Plan? T.V. Radio Billboard Newspaper Direct Mail Broker
Doctor Other
INDIVIDUAL PLAN FOR CHILDREN ONLY – If applying for child-only coverage (no adult application), Application
must be completed by the child’s Parent or Legal Guardian.
I am the child’s: Parent Legal Guardian (Please attach copies of guardianship documents with submission of Application)
Parent/Legal Guardian – Last Name, First Name, MI: Home Telephone: Business Telephone: Cellular Telephone:

Mailing Address: Apt. # City: State: Zip Code: Email Address:

OTHER APPLICANTS YOU WISH TO COVER

Last Name, Relationship DOB Gender Social Height Weight Choose one deductible
First Name, MI to Primary (m/d/y) Security # (ft., in.) (lbs) option below, for each
Applicant Applicant
1. M 20%/$250 30%/$1500
F 20%/$500 30%/$2000
20%/$750 30%/$4000
20%/$1000
20%/$2000
2. M 20%/$250 30%/$1500
F 20%/$500 30%/$2000
20%/$750 30%/$4000
20%/$1000
20%/$2000
3. M 20%/$250 30%/$1500
F 20%/$500 30%/$2000
20%/$750 30%/$4000
20%/$1000
20%/$2000
4. M 20%/$250 30%/$1500
F 20%/$500 30%/$2000
20%/$750 30%/$4000
20%/$1000
20%/$2000
LINC 180-0507 Page 2 of 6
Lovelace iPlan Enrollment Application
SECTION II: HEALTH QUESTIONNAIRE – must be completed for each individual applying for coverage
The information provided in this Health Questionnaire is used to evaluate the medical risk of each individual Applicant and is used
in accordance with Lovelace Insurance Company’s Underwriting Guidelines. Omissions of medical information and/or misstatements
of medical information, which is material to the underwriting decision, can void or cancel the Policy. Acceptance or denial of an
Application is based on each individual. This Health Questionnaire shall become part of the contract between each member and
Lovelace Insurance Company. If one individual is denied, the other members of the family may still be accepted.
Directions: Please check “Yes” or “No” for each question. If you answer “Yes” to any question on this page, please provide
complete details in the “Details of Medical History” section. Please indicate if you or any other applicants listed on this
Application have been advised, counseled, diagnosed, tested, treated, recommended for treatment, or hospitalized within
the past 5 years (10 years for cardiac or cancer) for any of the following:
A. Cardiac (if in last 10 yrs), Heart Problems, Stroke, Circulatory, Vascular Disease, High Blood Pressure, Yes No
High Cholesterol/Triglycerides
B. Cancer (if in last 10 yrs), Tumors, Cysts, Leukemia, Lupus or any other Systemic Diseases Yes No
C. Multiple Sclerosis, Paralysis, Arthritis, Gout, Rheumatoid Arthritis, Bone/Joint/Back or Muscle Disorders Yes No
D. Allergies, Asthma, Emphysema, Respiratory or Lung Disorders, COPD Yes No
E. Eye Disorders, Cataracts, Ear, Nose, Sinus, Tonsil, Adenoid Yes No
F. Diabetes, Pancreas, Thyroid, Growth Disorders or Endocrine Disorders Yes No
G. AIDS, HIV, Sexually Transmitted Diseases, Immune System Disorders or Blood Disorders Yes No
H. Hepatitis, Cirrhosis, Liver Disorders, Digestive System Disorders, Colon Disorders, Hernia, Gallbladder,
Gastrointestinal Disorders Yes No
I. Kidney, Bladder, Prostate, Reproductive Organs Disorders, Infertility Yes No
J. Migraines, Brain/Nervous System, Seizure Disorders, Mental/Emotional Disorders, Depression, Yes No
Suicide Attempt(s), Epilepsy
K. Alcohol, Drug, Chemical, Substance Use, Abuse or Dependency or Treatment Yes No
L. Organ, Tissue or Bone Marrow Transplants Yes No
M. Is any applicant pregnant or an expectant father? Yes No
Who? Due Date:
N. Were previous pregnancies complicated or high risk? If not applicable, check “no.” Yes No
O. Is any applicant currently taking any prescription medication(s)? Yes No
P. Is there any condition not previously listed that has been a medical concern? Yes No
Q. Is there any medical treatment or procedure that has been advised, but not yet done? Yes No
R. Has any applicant used cigarettes or other tobacco products in the past 24 months? Yes No
S. Has any applicant consulted a medical provider for any other reason other than what has been indicated already? Yes No
SECTION III: OTHER COVERAGE INFORMATION
A. If one or more family members were declined for coverage, would you like to cover the remaining Yes No
family members?
B. Have you or any family members listed on this Application ever been covered by Lovelace Health Plan Yes No
or Lovelace Insurance Company? If yes, please complete the following:
Member Name Member# (aka LH#) Group Name Coverage Dates

C. Are you or any family members listed on this Application currently covered by any health insurance Yes No
carrier other than Lovelace? If yes, do you intend to keep this coverage if accepted for this plan?
If yes, please complete the following:
Covered Person: Carrier/Insurer:
Type: Group Individual COBRA/Continuation Other
D. Have you or any family members listed on this Application ever been denied, charged an extra premium for, Yes No
rescinded, cancelled, or had an exclusionary rider applied to health insurance?
If “yes”, please provide name of insurance carrier and explain:

LINC 180-0507 Page 3 of 6

Lovelace iPlan Enrollment Application
SECTION IV: DETAILS OF MEDICAL HISTORY
If you answered “Yes” to ANY of the questions asked in the Health Questionnaire above, please provide additional information using
the chart below. Please use example below, as a guide. Attach and label another page if necessary.

Reason for visit, condition, injury,

Medications
symptom or diagnosis Testing results,
Item prescribed Testing
treatment,
Letter (quantity/dosag Physician
Applicant Name Condition or Date of Date of advice given
e/frequency)
Diagnosis onset last treatment

Dr. Smith,
Internal
Checkup Use of inhaler, Advair, 10 mg,
D Trudy Asthma 3/2000 Medicine,
9/2006 daily twice per day
Albuquerque,
NM

LINC 180-0507 Page 4 of 6

Lovelace iPlan Enrollment Application
SECTION V: AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENTS – Payment for All Applicants
listed on this Application must be drawn from the same account. Any Applicant wishing to use a different routing
or account number, must complete a separate Application.
Upon approval and enrollment in the Lovelace Individual Plan, I hereby authorize and request Lovelace Insurance Company to initiate
automatic deduction entries from the account and financial institution indicated below for the monthly Premium payments required
by the Lovelace Insurance Company and explained in the Individual Plan Evidence of Coverage. These deductions are for Premium
payments only for each approved and enrolled individual listed in Section I of this Application. Premiums are due monthly via
Electronic Funds Transfer (EFT). Please do not include a premium payment with this Application. Premiums are based upon age,
gender, area, and tobacco-use.
Acknowledgements:
1. This authorization includes any future rate adjustments, and is to remain in effect until I provide 30-days prior notice to Lovelace
Insurance Company that my coverage is to be terminated.
2. Premium rate changes may occur:
a. At the Plan’s annual anniversary date for all Members;
b. On the first day of the month following my birthday, if my newly attained age moves me to a different age-based premium
bracket (a.k.a.age band) specified on the Rate Matrix.
c. If I or any of my family members move into or out of the “Albuquerque Area” , which is defined as all zip codes within the
counties of Bernalillo, Sandoval, Valencia, and Torrance.
d. Upon any changes in State or Federal law; or
e. Upon 60-days prior written notice from the Plan.
3. I will not receive a monthly billing statement from the Plan.
4. Pre-arranged premium deduction entries from a designated checking account are the required method of premium payment
under the Member Agreement. It is my responsibility to ensure that sufficient funds are available in the designated account prior
to each month’s deduction. Deductions will occur on the 3rd day of each month. If the 3rd day falls on a weekend or a banking
holiday, the deduction will occur on the following business day.
5. My first automated deduction for this plan may be equal to two months of premium because of the time required to set up
automatic payments. Thereafter, only one-month’s premium will be withdrawn each month.
Name of Financial Institution: Account Holder:

Financial Institution Transit Routing Number Account Number

(9 Digits – See diagram below): (See diagram below):

You Must Attach a Voided Check for Financial Institution and Account Information Verification.;
Your Name Check #123
Your Address
Your City, State, Zip

Date

Pay to the order of

In the amount of: Dollars

Please Attached an Unsigned Voided Check Here.

Financial Institution Name

For:

|: 123456789 :| 00998765432

This is your bank’s Transit Routing Number This is your Account Number
Account Holder’s Signature: Date:

LINC 180-0507 Page 5 of 6

Lovelace iPlan Enrollment Application
SECTION VI: REPRESENTATIONS, ACKNOWLEDGEMENTS, AND AUTHORIZATIONS
I hereby consent, to the extent permitted by applicable law, to 3. I understand that authorizing this disclosure of this health
the release of or use of my protected health information (PHI) by information is voluntary. I can refuse to sign this authoriza-
any person or entity including, without limitation, practitioners, tion, however, I understand that in not doing so may delay
pharmacies or pharmacy benefit managers, providers, and or inhibit the processing of this Application.
insurance companies to Lovelace Insurance Company or its 4. I am making this authorization for myself and/or as a legal
designees for any permitted purpose, including but not limited guardian of a minor child(ren). I understand that this authori-
to, insurance eligibility, quality assurance, utilization review, pro- zation will remain in effect until I send a written notice revok-
cessing of claims, financial audits or other purposes related to ing authorization to Lovelace. This authorization may be
the treatment, payment or healthcare operations activities of relied upon by Lovelace and other parties until revoked or
Lovelace Insurance Company. expired after twenty-four (24) months from the date this
I understand that it may be necessary for the parties administer- Application was received by Lovelace. I understand that any
ing the plan in which I am enrolling to obtain and/or provide to revocation will not be effective for any information disclosed
others “Confidential Information,” also known as “Protected upon previous release of this authorization.
Health Information,” as defined below. Therefore: 5. I understand that any information that is disclosed pursuant
to this authorization is no longer covered by federal rules
1. I authorize any person or entity having Confidential governing privacy and confidentiality of health information.
Information to provide any such Confidential Information
upon request to Lovelace, and its participating providers, or Applicants may revoke this authorization by writing to:
any entity performing a service for the purpose of eligibility Lovelace Insurance Company HIPAA Privacy Officer
determination under the plan, the administration of the plan, 4101 Indian School Rd, NE
the performance of any Lovelace program or operation, or Albuquerque, NM 87110
assessing of health care services and supplies. “Confidential Information” means, with respect to me and/or a
2. I authorize Lovelace to disclose any Confidential Information covered dependent/minor child, any medical, dental, mental
to any person, company or entity when it determines that health, substance abuse, communicable disease, DISA and
such disclosure is necessary or appropriate for the adminis- HIV related information and disability or employment related
tration of the Plan, the performance of Lovelace programs or information.
operations, assessing quality and accessibility of health care
services and supplies, or reporting to third parties involved in “Lovelace” means Lovelace Insurance Company and other
plan administration. entities to which Lovelace Insurance Company has delegated
services to perform.
I agree: By signing this Application, I understand and agree that I have read this Application thoroughly and have verified the accura-
cy of all information contained herein, whether entered by me, my legal spouse or by my parent or legal guardian. I hereby warrant
and represent my current and continuing authority to act on behalf of myself and/or my legal dependent child(ren) under age 18 with
respect to every provision of the Agreement. All information on this Application is correct and true. I understand that this information
is the basis on which coverage is issued under the plan. I understand that if approved, I will receive my Lovelace Individual Plan
Evidence of Coverage and Summary of Benefits, which contains the benefits, limitations and exclusions applicable to my health care
plan. I further understand that if approved, I will also receive my Member Agreement that will provide written confirmation of my
membership in the Individual Plan, details regarding my benefits, my effective date and anniversary date, the amount of my automatic
monthly premium deductions and other information. My signature below will also serve as my acceptance of, and signature on, the
Member Agreement.
I further understand that any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an Application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
I understand that I am entitled to a copy of this signed Application and may contact Lovelace to obtain a copy.
By signing below, I certify that the answers provided are correct, complete and wholly true to the best of my knowledge and belief. By
completing this Application, I understand that I warrant and represent my current and continuing authority to act on behalf of myself,
my legal spouse and all legal dependent child(ren) under age 18 listed above. Coverage is subject to preexisting condition exclusions,
waiting periods, creditable coverage periods, and affiliation periods as allowed by New Mexico law. Premium, price or charge differ-
entials because of gender or age based on objective, valid, and up-to-date statistical and actuarial data are not prohibited.
I certify that my employer is not paying for any portion of this premium now nor in the future, should coverage be offered.
This Application must be signed and dated within 90-days of requested effective date by all adult applicants including yourself and
your legal spouse and/or any dependent child(ren) age 18 or over. The parent/legal guardian must sign and date the Application on
behalf of any legally dependent child(ren) under age 18. Signature is not required for dependent child(ren) under age 18.
Primary Applicant’s Signature (and/or Parent /Legal Guardian for dependent child-under age 18)
X Date:
Additional Applicant’s Signature (ONLY if age 18 or over and applying for coverage)
X Date:
Additional Applicant’s Signature (ONLY if age 18 or over and applying for coverage)
X Date:
Additional Applicant’s Signature (ONLY if age 18 or over and applying for coverage)
X Date:
Additional Applicant’s Signature (ONLY if age 18 or over and applying for coverage)
X Date:

LINC 180-0507 Page 6 of 6